Abnormal Uterine Bleeding


During each menstrual cycle, changes in your reproductive organs prepare your body for pregnancy. If you don't become pregnant, the uterine lining (endometrium) breaks down, causing bleeding. This is called menstruation. There are many variations of normal menstruation. A normal period can last from 2-8 days. The normal length of the cycle (from the first day of one period to the first day of the next period) can range from 21-45 days. The amount of blood lost varies from one woman to another but should not be enough to cause anemia. The menstrual cycle is controlled by hormones (chemical messengers that travel in the bloodstream). A medical history and pelvic exam may be all your healthcare provider needs to begin to diagnose your abnormal uterine bleeding. You may be asked to keep a record of your bleeding pattern. Sometimes, further diagnostic tests will be needed, such as lab testing, a pelvic sonogram, or a endometrial biopsy are necessary. Treatment of abnormal uterine bleeding varies depending upon the cause of the problem and may be medical or surgical.

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More than 1/2 of women who menstruate have some pain for 1-2 days of their menstrual cycle. Usually, the pain is mild. But sometimes, the pain is so severe that it keeps them from participating in normal activities, such as going to school or work. Pain this severe is called dysmenorrhea. Causes of dysmenorrhea are endometriosis, uterine fibroids, and the natural production of prostaglandins that occurs at the onset of the menstrual cycle. During your evaluation, your healthcare provider may perform a pelvic exam, order lab tests, and possibly order a pelvic sonogram. In some cases, surgical evaluation is necessary. Treatment for dysmenorrhea may include medications and techniques to relieve pain. If the cause of dysmenorrhea is found, treatment will focus upon removing or reducing the problem.

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The lining of the uterus is called the endometrium. Sometimes, endometrial tissue grows elsewhere in the body, usually within the pelvis. When this happens, it is called endometriosis. The main symptom of endometriosis is pelvic pain. Pain may occur with intercourse, during bowel movements or urination, or just before or during the menstrual cycle. For some women, the pain is mild. For others, it can be severe. Sometimes, endometriosis can lead to infertility. If you have symptoms of endometriosis, your healthcare provider may do a pelvic exam, possibly order a sonogram, and may even recommend surgical evaluation and management. Treatment for endometriosis depends upon the extent of the disease, symptoms, and whether you want to have children. It may be treated with medication, surgery, or both.

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Menopause is defined as the time in a woman's life when the ovaries stop producing eggs and menstrual periods end. The average age of menopause is 51 years. Years before you stop having menstrual periods, changes in your hormone levels can lead to some of the symptoms of menopause. In addition to irregular periods, the most common symptoms are hot flashes, night sweats, sleep problems, and vaginal dryness. Menopause is a normal part of a woman's life and does not always need to be treated. However, the changes that happen before and after menopause can be disruptive for some women. For women with bothersome symptoms, there are a number of different treatments:

  • Hormone therapy — Women with bothersome hot flashes can usually get relief with postmenopausal hormone therapy. For women with a uterus, this would be a combination of estrogen and a progesterone-like medication. Women who do not have a uterus (eg, after a hysterectomy) need only estrogen. Hormone therapy is available in a pill that you take by mouth; a skin patch; a vaginal ring; and a skin gel, cream, or spray
  • Hormone therapy alternatives — If you are bothered by hot flashes but you cannot take or would prefer to avoid hormone therapy, there are alternatives. Although hormone therapy is the most effective treatment for hot flashes, non-hormonal alternatives are a good option for many women.
  • Vaginal treatments — There are several treatment options for women with vaginal dryness, including vaginal estrogen

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Ovarian Cysts

Many women get cysts on their ovaries during their childbearing years. A cyst is a fluid-filled pouch. It can be as small as a pea or larger than a grapefruit. An ovarian cyst often causes no symptoms. But, if a cyst twists or breaks, or simply becomes large enough, it may cause pain. Most ovarian cysts are functional - meaning they occur as a result of the natural process of ovulation. These tend to shrink on their own in 1-3 months. Other, less, common types of ovarian cysts will not resolve on their own and often require surgical treatment. Cysts are rarely cancerous in women under age 50. Diagnosis of an ovarian cyst typically requires a pelvic exam and often a pelvic sonogram.

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Pap Tests / HPV Testing

The Papanicolaou smear (Pap test) is a test used to screen women for cervical precancer or cancer. Testing for human papillomavirus (HPV) is another type of test for cervical cancer that can be used in women over age 30 in conjunction with the Pap test. The most important risk factor for cervical cancer is infection with the human papillomavirus (HPV). There are over 100 different types of HPV; however, most types of HPV do not cause cancer. At least 80 percent of women are exposed to the HPV virus during their lifetime. Most of the time, the body's immune system gets rid of the virus before it does harm.

HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area. It is not possible to become infected with HPV by touching an object, such as a toilet seat. Most people who are infected with HPV have no signs or symptoms. Most HPV infections are temporary and resolve within several years. In 10- 20 percent of people, the virus persists and they have a chance of developing cervical pre-cancer or cancer. However, it usually takes many years for HPV infection to cause cervical cancer.

Since HPV is transmitted by sexual contact, having multiple sexual partners is associated with an increased risk for cervical cancer. Condoms provide only partial protection. Smoking can increase the risk of cervical cancer up to fourfold, as does having a condition or taking a medicine that weakens the immune system.

A vaccine is available to help prevent infection with some types of HPV and is recommended for girls or women between the ages of 9 and 26 years.

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Pelvic Organ Prolapse

One or more of the organs inside the pelvis can drop from their normal positions. This problem is called pelvic organ prolapse. When it occurs, you may notice a feeling of fullness or pressure in the pelvis or back, problems passing urine or having a bowel movement, urine leakage, or problems with sexual intercourse. Pelvic organ prolapse may be caused by one or more of the following: vaginal childbirth, hormonal changes that occur with menopause, constant coughing (such as with chronic bronchitis or smoking), repetitive heavy lifting/straining, and being overweight. To help find out whether you have pelvic organ prolapse, your healthcare provider will do a pelvic exam. Other tests may be done depending upon the extent of your symptoms, including lab work, imaging tests, or urodynamics. Treatment for pelvic organ prolapse can be nonsurgical, such as pelvic floor physical therapy, Kegel exercises, lifestyle modification, use of a pessary (a device worn in the vagina to help support the prolapsed organs). You and your healthcare provider may decide that surgical treatment is the best option. Each type of pelvic organ prolapse is corrected in a specific way. Depending upon your specific problem(s), your surgery may include one or more of the following: anterior repair, posterior repair, enterocele repair, hysterectomy (with or without removal of the ovaries), vaginal vault suspension, or tension-free vaginal tape.

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Polysystic Ovarian Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a condition that causes irregular menstrual periods because monthly ovulation is not occurring and levels of androgens (male hormones) in women are elevated. The condition occurs in about 5 to 10 percent of women. The elevated androgen levels can sometimes cause excessive facial hair growth, acne, and/or hair loss. The cause of PCOS is not completely understood. It is believed that abnormal androgen levels may interfere with normal function of the ovaries. There is no single test for diagnosing polycystic ovary syndrome. You may be diagnosed with PCOS based upon your symptoms, blood tests, and a physical examination. Expert groups have determined that a woman must have two out of three of the following to be diagnosed with PCOS:

  • Irregular menstrual periods caused by anovulation or irregular ovulation.
  • Evidence of elevated androgen levels. The evidence can be based upon signs (excess hair growth, acne, or male-pattern balding) or blood tests (high androgen levels).
  • Polycystic ovaries on pelvic ultrasound

If ovulation does not occur, the lining of the uterus (called the endometrium) does not uniformly shed and regrow as in a normal menstrual cycle. Instead, the endometrium becomes thicker and may shed irregularly, which can result in heavy and/or prolonged bleeding. Irregular or absent menstrual periods can increase a woman's risk of endometrial overgrowth (called endometrial hyperplasia) or even endometrial cancer. PCOS is associated with elevated levels of insulin in the blood and type II diabetes. Many women with PCOS do not ovulate regularly, and it may take these women longer to become pregnant. Oral contraceptives are the most commonly used treatment for regulating menstrual periods in women with polycystic ovary syndrome. These medications protect the woman from endometrial (uterine) cancer or overgrowth by inducing a monthly menstrual period. They are often effective for treating problems with acne and abnormal hair growth. Anti-androgen medications and certain medications used to treat diabetes may also be used. For women that are overweight or obese, weight loss is one of the most effective approaches for managing insulin abnormalities, irregular menstrual periods, and other symptoms of PCOS.

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Premenstrual Syndrome [PMS] & Premenstrual Dysphoric Disorder (PMDD)

Premenstrual syndrome is a medical condition with a combination of emotional and physical symptoms that can disrupt your health, career, and personal life. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent. Premenstrual symptoms vary in type, timing, and severity from woman to woman, but as many as 80% of American women show one or more symptoms of PMS. The most common symptoms of PMS are premenstrual irritability, depression, bloating/weight gain, breast tenderness, and carbohydrate cravings. Symptoms similar to premenstrual syndrome may have many other possible causes, so your healthcare provider may ask you to keep a symptom diary for several months. He or she may also order lab tests and perform a physical examination. Treatment of PMS is aimed at raising serotonin levels. Good nutrition, good sleep, regular exercise, and stress management all help alleviate symptoms. In some cases, your healthcare provider will prescribe medication to augment these lifestyle changes.

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